Impact on the Spread of Communicable Diseases
Syringe Services Programs (SSPs) are community-based programs that provide access to sterile needles and syringes free of cost and facilitate safe disposal of used needles and syringes to prevent the spread of disease. Given the controversial nature of SSPs, they have produced a variety of policy responses from states. This brief will summarize the research on the impact of policies surrounding SSPs.
Syringe Services Laws in the US
Syringe Services Programs
Syringe Services Programs (SSPs) are also referred to as syringe exchange programs (SEPs), needle exchange programs (NEPs), and needle-syringe programs (NSPs).
The Centers for Disease Control and Prevention (CDC) estimated that in 2016,
nine percent of human immunodeficiency virus (HIV) infections in the United States were attributable to injection drug use (IDU). IDU is the most common means of transmitting hepatitis, and an estimated 30 percent of persons who inject illegal drugs aged 18-30 years are infected with hepatitis. Increases in IDU associated with the aftermath of the opioid crisis have led to greater interest in SSP’s. In order to ensure the legal operation of SSPs, several states have passed laws allowing for varying degrees of syringe services (Figure 1).
Miss. Code Ann. sec. 41-29-105, sec. 41-29-139
Prohibits the sale or distribution of drug paraphernalia, specifically defining syringes and needles as paraphernalia.
Laws relating to syringe exchange come in three primary categories: laws that allow syringe exchange statewide, laws related to the retail sale of syringes, and laws that include or exempt syringes from the classification of drug paraphernalia. Currently, 19 states have laws authorizing syringe exchange statewide, 27 states authorize the sale of syringes without a prescription, and seven states exempt syringes from their paraphernalia laws (Figure 1). Currently, Mississippi law does not explicitly authorize the exchange of syringes and categorizes syringes as paraphernalia but does not have a law prohibiting the retail sale of syringes without a prescription nor a law prohibiting sales specifically to people who inject drugs (PWID).
Syringe Services Policy Effectiveness
A growing body of research indicates that SSPs can be effective in reducing the spread of infectious diseases and getting injection drug users into treatment.
A growing body of research indicates that SSPs can be effective in reducing the spread of infectious diseases and getting injection drug users into treatment. Studies have shown that the availability of SSPs is associated with a greater than 60 percent reduction in the risk of contracting communicable diseases, such as hepatitis B and C, among injection drug users. Similar studies have shown that those who did not use a SSP when one was available were three times more likely to contract HIV than those who used the available SSP. A limited number of studies have documented negative impacts of these programs, including studies showing that users of SSPs are more likely to have HIV, the utilization of SSPs increases the risk of becoming HIV positive, and regular use of SSPs is associated with passing of contaminated syringes. A few studies show no difference in the risk of becoming HIV positive between users of SSPs and non-users.
In 2010, an international literature review was conducted of 45 studies evaluating the effectiveness of SSPs. Researchers found that most of the available studies suggest SSPs do attract a high volume of HIV positive individuals, but SSPs are not associated with a higher risk of becoming HIV positive. The 2010 review also found that SSPs do attract a high volume of persons who inject drugs, but SSP attendance does not increase syringe sharing, borrowing, lending, or reuse. A systematic review conducted in 2013 of 15 studies and subsequent research including a 2014 meta-analysis of 12
studies and a 2017 Cochrane review found evidence that syringe exchange programs are associated with reductions in HIV transmission, and a combination of SSPs and opioid-substitution therapy could reduce the risk of hepatitis C transmission among PWID.
Much of the opposition to SSPs derives from moral, social, or cultural concerns.
Much of the opposition to SSPs derives from moral, social, or cultural concerns. One of the primary concerns with SSPs is that federally funding SSPs would contradict law enforcement efforts to stop illegal drug use and amount to a tacit approval of drug use. In 2010, the federal ban on funding SSPs was lifted for a short time until 2012, when the ban was reinstated. Research conducted in 2015 specifically evaluated the impact of the federal policy change to allow for local funding for SSPs in the District of Columbia. Researchers found that the policy change had a significant and immediate impact on the decline in incidence of new HIV infections attributable to injection drug use (IDU), and the policy would have had a sustained impact had it remained in place.
Funding for Syringe Services Programs
A recent national level economic evaluation of return on investment for SSPs showed SSPs deliver a financial rate of return between $6.38 and $7.58 for every dollar spent.
Funding SSPs has been shown to be cost effective and to have a significant impact on the performance of SSPs. A recent national level economic evaluation of return on investment for SSPs showed SSPs deliver a financial rate of return between $6.38 and $7.58 for every dollar spent. Research shows that approximately 50 percent of SSPs receive state and local government funds. Funding from state and local government is associated with larger numbers of syringe services per year, more total services offered, and a greater likelihood of offering counseling and testing. Among programs that receive state and local government funding, this funding accounted for approximately 87 percent of their budget for syringe services. Foundation grants and private donations are the two other major sources of funding for SSPs.
HIV and HCV Treatment Costs
The lifetime cost of HIV treatment is estimated to be $379,668 (in 2010 dollars) and the market price of hepatitis C treatment ranged from $84,000 to $96,000 in 2014. These costs raise significant budgetary issues for Medicaid and health insurance plans.
SSP Support Services Other than syringes & needles
- Counseling
- Screening
- Prevention
- Vaccinations
- Provision of Naloxone
- Mental Health Services
- Physical Health Care
Social Services - Recovery Support Services
- Referral to Coordinated Substance Use Disorder Services
The most recent federal guidance on using federal funds for syringe services comes from the Consolidated Appropriations Act of 2016, which maintains the prohibition on the use of federal funds to purchase syringes for the purpose of illegal drug use. Federal law was modified in 2016 to relax limitations on the use of federal funds by state health departments in consultation with the Centers for Disease Control and Prevention (CDC) for SSP support services other than the purchase of needles and syringes, based on evidence of a demonstrated need. A state can demonstrate need by experiencing, or being at risk for, significant increases in hepatitis infections or an HIV outbreak due to injection drug use. Under CDC and Department of Health and Human Services guidance on the use of federal funds for SSPs, state laws would still control whether a syringe services program or the sale of syringes could be authorized.
Only ten states, including Mississippi, have not requested an at-risk designation from the CDC.
In order to be approved to use federal funds for these purposes, a state must request a determination of need for SSPs. As of May 2019, 37 states and the District of Columbia have been declared jurisdictions experiencing or at-risk of significant increases in hepatitis infection or an HIV outbreak due to injection drug use. Only ten states, including Mississippi, have not requested an at-risk designation from the CDC. In 2015, there were approximately 200 SSPs in 33 states, and as of 2018, there were 320 SSPs in 41 states (Figure 2).
Policy Considerations
Research indicates that state and federal policies have a direct impact on the existence and effectiveness of SSPs. In a comprehensive study prepared for the Centers for Disease Control and Prevention it was recommended that the federal government repeal the ban on the use of federal funds for syringe exchange services and commit substantial federal funds to providing syringe exchange services and to expanding research. The study also recommended several policy options for states: repeal their laws requiring prescriptions for access to syringes, repeal paraphernalia laws applying to syringes, and allow for the sale of syringes without a prescription.
In the wake of the opioid crisis the National Center on Addiction and Substance Abuse made several policy recommendations including changing state laws to authorize the distribution of sterile syringes and changing state laws to allow for access to state funding for SSPs. Recently, Indiana adopted the policy approach of changing state law to provide an exception to prohibitions on SSPs during disease outbreaks. Delaware and Kentucky recently passed legislation authorizing statewide SSPs that provide referrals to drug treatment. Legislation passed in 2016 in North Carolina permits government and non-government organizations to operate syringe services programs that may also distribute naloxone.
If Mississippi intends to use federal funds for SSP services, the state must request an at-risk designation from the Centers for Disease Control and Prevention as a jurisdiction experiencing significant increases in hepatitis infection or an HIV outbreak due to injection drug use. As a part of a recent federal initiative to eradicate HIV Mississippi was identified by the Department of Health and Human Services as one of seven states to be targeted due to a substantial rural HIV burden.
Sources
A more detailed report with sources is available at http://www.mshealthpolicy.com.
